Does Medicaid Cover Organ Transplants?

Organ transplants can be very costly. In 2008, the first year costs for a heart transplant was $787,700, according to Transplant Living.org. People are usually overly concerned about how they will pay for the cost of organ transplants. Many individuals who are without commercial health care insurance must rely on government programs, such as Medicare and Medicaid to pick up the majority of the costs. Whether Medicaid covers organ transplants, and to what extent, depends on the state where you reside.

Features

• The Medicaid program is a health care insurance program that provides health care coverage to low-income individuals and families with children. The program is actually a joint effort on the part of the federal government and the state. Each jurisdiction provides as much as 50 percent of the money to subsidize the program. Each state names its program, administers it and determines the eligibility requirements. The states are also responsible for deciding what benefits and services are allowed under their program. Some states do not provide funding for organ transplants.

Significance

• Even if you have private insurance, the amount of the coverage may not be enough to pay for all of the costs that are associated with an organ transplant. Often, transplant patients must depend on Medicaid as their secondary insurance plan to help pay for the remaining costs. Even after patients are released from the hospital, there are still expenses related to the life-long maintenance that will be required. The anti-rejection medication alone can easily cost $2,000 to $4,000 per month, as of 2009.

Considerations

• There are only two categories of "need" that states may use to determine health care eligibility under the Medicaid program. First, there is the "Categorically Needy." States are obligated to cover the clients under this classification. Included are low-income families with children, pregnant females, and infants and children with a level of income that is less than a certain percentage of the Federal poverty baseline, qualified Medicare beneficiaries and SSI recipients.

  The second category is called "Medically Needy"; it is also referred to as "Spend Down." This classification is not offered in every state. It allows individuals to subtract the health care expenses from their income. The purpose is to bring the income down to the Federal poverty level in order to qualify for Medicaid. Besides evaluating income, some states may also look at assets, such as whether you own a home or car.

Function

• There are eight types of organs transplants: kidney, pancreas, kidney/pancreas, heart, lung, heart/lung, liver and intestine. Whether or not Medicaid will pay for the type of organ transplant is determined by the agency administering the states' program. Even if a particular organ transplant is covered, there may be qualifying conditions and stipulations that apply. For example, North Carolina Medicaid program usually will not cover heart transplants for patients who are over the age of 65 or for patients who are obese, which is define as 130 percent of their "ideal body weight."

Expert Insight

• According to the University of Chicago Hospital, you should put together a plan to pay for the cost of your organ transplant costs. The basic plan entails three steps: having a good primary insurer, finding a good secondary insurance plan and looking into other ways to pay for the procedure, such as a fundraiser.

  You may have out-of pocket expenses. If you cannot afford your share of the costs, you should consider getting a secondary insurance plan. Fundraisers are also options that should be explored; many transplant facilities have a financial coordinator who can assist you. Some other sources, such as community groups and religious organizations, may also be able to provide you with additional direction and assistance.